The MICU is able to perform an LP. Opening pressure is 40cmH2O. Per IDSA guidelines, they remove 30mL CSF and are able to obtain a closing pressure of 20cmH2O, representing a reduction of 50%. They also start IV amphotericin B and flucytosine, with ID helping to guide therapy. The patient is found to be HIV-negative, so IRIS is less of a concern.
Her exam does improve, briefly. Unfortunately, there's some trouble repeating an LP, and she still has persistent intracranial hypertension. You ask your neurosurgery colleagues to consider placing an EVD. They evaluate her and, after you explain the situation with her plateau waves and the mortality benefit of treating her high ICPs from Crypto, they agree to do so.
She is unable to get the EVD weaned over the next two weeks. Fortunately, though, her intraabdominal infection has resolved. Neurosurgery opts to place a ventriculopleural shunt as her abdomen would not be hospitable to a shunt catheter. (In patients with cryptococcal meningitis that is NOT associated with HIV, shunts tend to be necessary more often.)
She eventually gets discharged to the floor, and then gets discharged to SAR thereafter, having spent a total of 5 weeks in the hospital.
Copyright © 2024-2026 Andrew M. Nguyen, M.D. For educational use only.
This work is licensed under
CC BY-NC-SA 4.0.
